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* 1. Date

Date / Time

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* 2. Name (optional)

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* 3. How likely is it that you would recommend this company to a friend or colleague?
(1 being not likely, 10 being extremely likely)

0 10
i We adjusted the number you entered based on the slider’s scale.

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* 4. In Your Home:

  Yes No
Do you choose food?
Do you go grocery shopping?
Do you do your clothes washing?
Do you answer your front door?
Do staff ring the doorbell before entering the house?
Do staff just walk in the house?

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* 5. Does your family visit?

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* 6. When your family visit do they talk to you or the staff

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* 7. Do the staff talk to you?

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* 8. Do staff knock on your bedroom door before walking in?

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* 9. Do the staff treat you well?

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* 10. Do you have ideas on what we could do differently or try?

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* 11. What do you enjoy and what should we keep doing?

T